A nurse is assessing a bedridden patient and notes a reddened area on the sacrum that does not blanch when pressed. The skin is intact. Based on this finding, which stage of pressure ulcer should the nurse document?

Stage I

Stage II

Stage III

Stage IV

Answer and Explanation

The Correct Answer is A

A. Stage I. A Stage I pressure ulcer is characterized by intact skin with non-blanchable erythema. The affected area may feel warmer or firmer than surrounding skin.

B. Stage II. A Stage II pressure ulcer involves partial-thickness skin loss, often presenting as a shallow open ulcer or intact/blistered skin. Since the skin is still intact in this scenario, it is not Stage II.

C. Stage III. A Stage III pressure ulcer involves full-thickness skin loss with visible subcutaneous tissue but no exposed bone, tendon, or muscle. This does not match the description of an intact but reddened area.

D. Stage IV. A Stage IV pressure ulcer involves full-thickness tissue loss with exposed bone, tendon, or muscle. This is much more severe than the described case.

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Correct Answer is A

Explanation

A. "I will wear non-slip socks while in the hospital to reduce my risk of falling." Wearing non-slip socks provides better traction and reduces the risk of slipping, which is especially important for patients with osteoporosis who are at higher risk for fractures.

B. "I will place small rugs throughout my house to prevent slipping." Small rugs can be a tripping hazard and increase the risk of falls. Patients should be advised to remove loose rugs or secure them with non-slip backing.

C. "At home, I should not wear my glasses nearby to avoid missteps." Patients should always wear their prescribed glasses to ensure clear vision and reduce the risk of tripping over obstacles. Poor vision can contribute to falls.

D. "I don't need to do weight-bearing exercises because they won't help my bones." Weight-bearing exercises, such as walking and resistance training, help maintain bone density and reduce the risk of osteoporosis-related fractures.

A. Apply an antibiotic ointment and reassess in two weeks. B. Refer the patient to a dermatologist for a biopsy. C. Reassure the patient that the lesion is benign and monitor for changes. D. Educate the patient on proper wound care and sun protection.

Correct Answer is B

Explanation

A. Apply an antibiotic ointment and reassess in two weeks. SCC is a form of skin cancer and requires biopsy for diagnosis. Simply applying an antibiotic and waiting could delay necessary treatment.

B. Refer the patient to a dermatologist for a biopsy. The priority action for a suspicious lesion that does not heal is to refer the patient for biopsy and further evaluation, as early detection and treatment of SCC are crucial.

C. Reassure the patient that the lesion is benign and monitor for changes. SCC can be aggressive if untreated, and assuming benignity without biopsy could result in delayed diagnosis and worsening prognosis.

D. Educate the patient on proper wound care and sun protection. While wound care and sun protection are important, the priority is obtaining a definitive diagnosis through biopsy.

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A nurse is assessing a bedridden patient and notes a reddened area on the sacrum that does not blanch when pressed. The skin is intact. Based on this finding, which stage of pressure ulcer should the nurse document?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is educating a patient with osteoporosis about fall prevention strategies at home and in the hospital. Which statement by the patient indicates a correct understanding of the teaching?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

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